ANCILLARY DENTAL WORKERS (AMENDMENT) REGULATIONS (Hansard, 28 June 1978)

§ The Under-Secretary of State for Health and Social Security (Mr. Eric Deakins)
I beg to move, That the draft Ancillary Dental Workers (Amendment) Regulations 1978, which were laid before this House on 6th June, be approved. These regulations, as drafted by the General Dental Council, have been approved by the Privy Council under Section 41(9) of the Dentists Act 1957, and on behalf of the Privy Council I now commend them to the House. They amend the Ancillary Dental Workers Regulations 1968, as amended in 1974. These regulations provided for the setting up of rolls of ancillary dental workers. They also specified the kinds of work that dental hygienists and dental auxiliaries might undertake—scaling, polishing, applying prophylactic materials, giving oral hygiene advice, and, in the case of auxiliaries, extracting deciduous teeth and doing simple fillings.
The changes proposed are to increase at the end of this year the fee for first enrolment to £4 and the annual fee for retention of a name on the rolls to £3. The fee for first enrolment has stood at £2 since 1968, and the fee for retention was last increased from its 1968 figure of £1 to £1.50 in 1974. The Privy Council is of the opinion that the proposed fees are justified by changes in circumstances which have taken place. The income from enrolment and retention fees helps the General Dental Council to meet the administrative costs of maintaining the rolls of dental auxiliaries and dental hygienists, exercising supervision of training and examinations and generally of safeguarding the public by the maintenance of standards of practice.
When I say that in 1977 the General Dental Council's costs directly related to ancillary dental workers were estimated to be £6,400, and that total income of the Council from the proposed amended fees in 1979 is expected to amount to less than £6,000, the House will appreciate that the proposals are modest in character. They are such as are necessary to assist the General Dental Council to meet rising costs in carrying out its statutory 1521 functions in regard to ancillary dental workers.

§ Mr. Robin Hodgson (Walsall, North)
In looking through some of the documentation on the background to ancillary dental workers, I came across a familiar if rather dry description of a sensation that many people feel when approaching the dentist: The fear of pain during a dental appointment is a common cause for anxiety both in the Research Dental Care Unit and elsewhere. This anxiety does not seem to lessen markedly with time for it was stated as a reason for feeling tense by over half the patients at all the courses of treatment. I think that that is a common experience that all hon. Members have felt when approaching their dentist, and although tonight I am not expecting to suffer any pain, I must admit to feeling slightly tense because I am speaking from a slightly unfamiliar position. Nevertheless, I am pleased to be able to have the opportunity of raising a number of points on this Statutory Instrument, which covers the operation of ancillary dental workers.
This is not least because the work of ancillary dental workers—and of dentists generally—is rarely discussed on the Floor of the House. Looking back to previous debates, I see that the last reference was in February 1974, when the minds of most hon. Members were on things other than the work of dentists. Before that, one has to go back to 15th February 1968. In that debate reference is made to the previous debate, which occurred in November 1955. By that cycle of events, it will be 1988 or 1990 before we debate dentists and dental ancillaries again, and I am glad to have the opportunity to raise one or two points with the Under-Secretary of State tonight in relation to the future role of the dental ancillary workers.
I begin with a familiar and personal complaint about the explanatory notes which form part of Statutory Instruments. This is something that we have raised before, and I know that the hon. Gentleman has taken the point, particularly in regard, for example, to the Statutory Instrument dealing with overlapping social security benefits. But here we have a four-line note which does little other than repeat what is clearly expressed in the text, with the exception that it refers 1522 to the amount of the fee prior to the proposed increase. I believe that if Statutory Instruments are to catch the imagination of more hon. Members, this sections needs to be made more explanatory as opposed to merely descriptive of what has gone before.
I understand that there are two classes of ancillary workers—the hygienists, now numbering about 1,505, and the dental auxiliaries, numbering about 500. The numbers are increasing in the case of the hygienists by about 90 per annum and in the case of the dental auxiliaries by about 30 per annum. By my calculation, it would seem that, from the proposed increases of fees in this Statutory Instrument, the increased income will be about £2,500 rather than the £6,000 to which the hon. Gentleman referred—namely, £2 times 120—the number of additions to the register and £1.50 times 1,500—the number of names retained on it. It seems to me that in either case, as the hon. Gentleman says, the amount of fee is modest.
In view of the costs and the administrative time and difficulties that must be involved in bringing forward this Statutory Instrument, one wonders whether the purpose would not be better served either by postponing it until a time when a larger increase could be undertaken or, indeed, by structuring the increase in fees in a different way.
In this context, I refer to the relationship of the fees charged to the ancillary workers as opposed to the full dentists themselves. Whereas on the first registration a dentist is charged £7 and an ancillary is charged £4—a ratio of about 2:1—for retention on the register the dentist is charged £22 and the ancillary is charged only £3—a ratio of about 7:1. In terms of restoration to the register—this is admittedly a problem of the least significant category—the ratio is 5:1. It seems that there could be a means of either improving the revenue or, indeed, of making the relationships between the registration fees charged to the two classes of dental practitioners more directly comparable.
I turn from that to one or two broader issues that lie behind the proposal to increase the fees. I turn, first, to the question of preventive medicine. In a debate about three weeks ago on the 1523 Select Committee report and the Government's response, "Prevention and Health", a great deal of stress was placed on the need for preventive dental care. This is important in the context of what we are discussing tonight, since the ancillary dental workers, both auxiliaries and hygienists, are in the forefront of preventive dentistry, and were, as the Minister stated, set up with this purpose in mind.
In the Select Committee's report, recommendation 72, on page 66, was that more dental hygienists should be trained and employed. But the response of the Government to this, in their reply on recommendation 38, was only category B, which means "accepted with reservations". I think that it would be interesting for us to know a little bit more about the way in which matters are proceeding in the implementation of that recommendation.
Secondly, there is only one dental auxiliary school in the country, which, I understand, is at New Cross in London. It has a smallish output and a fairly high wastage of students. I understand that this has been explained by the fact that most of the trainees there are girls of the age of 18 to 20, to whom the social attractions of London often prove more compelling than the dentist's treatment room.
But there has been, as I understand it, a recommendation by the Court Committee that two further auxiliary dental schools be established. It would be useful if the Government would let us know what progress, if any, is being made on that proposal, for it is patently unsatisfactory for us to discuss this Statutory Instrument, which concerns the basic regulations covering ancillaries, without knowing anything about future Government plans in this field.
If that is one side of the equation, the other side is of course, the cost side—the cost of doing nothing. Parliamentary Questions have revealed that dental disease is now estimated to cost 600,000 working days per annum and a loss of production of about £3 million, and that only three adults in 1,000 have a full set of natural teeth. Then there is that statistical marvel, with which I am particularly entranced, the "average English- 1524 man" who has no teeth by the time he is 42.
I might be tempted, in that context, to say that the Minister is abnormal—though, of course, only in a statistically dental sense. Nevertheless, underlying that remark there is the important point of the Government's attitude with regard to dental ancillaries in relation to their preventive role in the community.
I turn now to a second area and ask the Minister whether the Statutory Instrument presages any changes in the position of dental ancillaries. First, some concern has been expressed by the dental profession at a possible lowering of standards as a result of the extension of the role of the dental ancillary worker.
I understand that the dental auxiliaries are keen to change their title to "dental therapists"—presumably believing this to be a more highly prestigious professional name. At the same time, will the severe restraints on auxiliaries, some of which the Minister mentioned—the fact that they are restricted to local authority or hospital service and cannot go into general dental practice—be loosened, changed or amended in any way? I think that the dental profession has expressed some concern on this matter, and the Minister has an opportunity tonight to confirm its fears or to calm them as the case may be.
At the same time, there is a changing role for dentists in the community, and I think that it would be helpful if the Minister could say something about the way in which the future of ancillaries will take that into account. The World Health Organisation regional office for Europe has produced a pamphlet entitled "Implications for the Training of Dentists and Dental Auxiliary Personnel". Perhaps I may quote briefly from two parts of that document. It says: The dentist, having received prolonged and expensive training, spends much of his professional life carrying out semi-skilled procedures and soon finds himself, through lack of time or experience, unable to carry out the treatment or to give the advice that many of his patients require and that he has been trained to provide. Elsewhere, the pamphlet says: In few, if any, dental schools are undergraduates trained to utilise fully the assistance of dental auxiliary personnel. They are trained to operate with the minimum of auxiliary assistance of any kind. The oral health of the 1525 community can be attained through the treatment and education of the individual. Consequently, undergraduate training is oriented towards treatment of the individual patient, which makes such heavy demands of the dentist that the wider objectives of community health tend to be lost sight of. It is desirable that, in addition to training an undergraduate in his special subject, he should also be trained as part of a wider unit comprising different personnel concerned with the elimination and prevention of dental disease. This should be a team approach. Also, within the profession itself, there seems to be a considerable shift of attitude, because in the examination of various expert witnesses by the Select Committee, as is made clear in its report, my hon. Friend the Member for Chislehurst (Mr. Sims) asked Professor Curson, professor of consultative dentistry at King's College dental school, what the attitude of members of the profession was towards hygienists and whether they would be prepared, particularly those of the old school, to take in more hygienists and auxiliaries. Professor Curson replied: Inevitably there should be some of the old school who would continue like this"— that is, to ignore them— but I think on the whole the profession, particularly the younger members, for example our own students, look to hygienists for health. They like to co-operate with them in many ways. Most of the young people would welcome it, the young graduates, and I think the vast majority of dental practitioners would welcome this assistance. In the light of changing attitudes in terms of research and in the profession, I think that it would be helpful if the Minister could say whether the Statutory Instrument takes us into areas which are likely to reflect some of the changes that I have mentioned.
The third area of concern is in the general effectiveness of dental ancillary workers. Professor Allred from the experimental dental care project, has produced a series of essays, which I think has gone to the Department, entitled "Assessment of Quality of Dental Care." The professor has produced a number of statistics concerning the relative cost of using auxiliaries as opposed to dentists, which he assesses as costing 3.6p per minute as opposed to 10p per minute. It would be helpful to know whether those are figures on which the Minister is basing his policy developments.
1526 I come next to the question of the effectiveness and results of auxiliary care. An article by Mr. Sutcliffe in the British Dental Journal entitled "Dental Auxiliaries—a method of measuring their clinical usefulness" suffered from a grave weakness in that it covered only one dentist working with one auxiliary. It showed a 64 per cent. increase in the number of patients seen each day. I should like the Minister to say whether his Department is looking at any other studies and any other bases on which the effectiveness of dental auxiliaries is being measured.
Finally, there is the question of better data to cover the effectiveness of treatment. Again, I turn briefly to the Select Committee's report. Professor Curson gave an interesting example when he was questioned on the measurement of the effectiveness of preventive dentistry. In answer to a question he said that he could not say precisely what was required, but added: It is not criticism of the Board itself —that is, the Dental Estimates Board— but a number of years ago they reorganised the method of accounting and they established a very large computer system for recording all the work that was done. At the time I did know the gentleman concerned and in my view it is a great pity that we do not know from the Dental Estimates Board how many people were treated, we cannot identify from the Dental Estimates Board how long any particular treatment lasts. They make an ad hoc assessment by a random sample method but it would have been so easy at the time —and it may be impossible now—to have identified patients on particular courses of treatment. Again, in considering the broader issue of dental auxiliaries and ancillaries generally, and the future of that body of workers, could the Minister not see whether he can find a way of improving the quality and extent of the knowledge and the statistics on which we are basing our decision tonight.

§ Mr. Deputy Speaker (Mr. Oscar Murton)
If the hon. Gentleman would take a little advice from the Chair in the kindest possible way, he should relate this question to the matter of fees. It would bring him nicely back into order on this subject.

§ Mr. Hodgson
I am just coming to my conclusion, Mr. Deputy Speaker. I was seeking to draw the Under-Secretary's 1527 attention to the fact that in considering the increase of fees, which we are doing tonight, we have to consider the effectiveness of dental ancillaries, and we might wish to alter the fees dramatically if we felt that this important body of workers was not making a satisfactory and useful contribution to the dental care of the nation and to preventive dentistry generally.
In conclusion, I have asked the Minister a good many questions about his plans for the ancillary dental profession, some of which he may be unable to answer straight away. But we are discussing an important issue tonight, for by any standards, dentists need more help—first, help in the practice of preventive dentistry and, secondly, help in providing treatment. Not only must the care be effective; it must be acceptable to both providers and patients. There must be job satisfaction for the personnel and an opportunity for them to realise their ambitions. It is in pursuit of this triple objective—effective care, job satisfaction and career opportunity—that I raise these points tonight.

§ Mr. Deakins
With permission, I would like to respond to the debate. Perhaps I could begin by congratulating the hon. Member for Walsall, North (Mr. Hodgson) on his maiden speech from the Opposition Front Bench. I know how difficult these occasions can be because not long ago I was performing that very role. I know how difficult it is to make such a speech on such a very narrowly constructed motion. I remember on one occasion being pulled up two or three times within ten minutes by one of your predecessors in the Chair, Mr. Deputy Speaker, for straying beyond the bounds of order. I must confess that I was bemused and did not understand what I was doing wrong until it was explained to me afterwards.
Without straying beyond the bounds of your tolerance, Mr. Deputy Speaker, I hope that I can reply briefly to the points which the hon. Gentleman has made. First, the explanatory note is short because the regulations themselves are extremely short, perhaps substituting two or three figures for others in the main regulations. While I appreciate the hon. Gentleman's desire to have a rather 1528 longer background note, what he is asking for is not so much an explanatory note on the regulations, because that must be done by the construction of the regulations. It cannot go beyond what is contained in them.
I believe that the hon. Member wants the kind of background note that Ministers have. Having been a Back Bencher for a long time, and still being one at heart, I see no reason why for those who are interested we could not make available a longer background note. I can assure him that when we have had debates upstairs in Committee I have always bent over backwards to provide as much background information as possible to hon. Gentleman so that a better informed debate could result, in the interests of both Government and Opposition.
The hon. Member's second point was whether these regulations should be brought in now or whether they should be postponed until there could be a larger increase. My feeling is that they have already been delayed in the sense that the figures have not been increased for four years, and this in a time of a fair amount of inflation. I feel that the General Dental Council has been very modest in its requirement.
As I explained, the Council has kept the extra income that it will get from these regulations well in line with its expected expenditure in 1979. Had the Council delayed, a bigger increase might have been necessary, and I am not sure that such an increase for dental hygienists and ancillary workers would have been a good thing because their pay scales, although reasonable, are not extravagant and we must bear in mind their financial position when considering the level to which we should increase fees. The ratio of these fees to dental fees is a matter for the GDC, and I am sure that it will take note of the suggestions of the hon. Member for Walsall, North.
On the training of dental hygienists, we have replied to recommendation 38 of the Expenditure Committee in our White Paper. I refer the hon. Gentleman to paragraphs 125 and 126. I have the details here, but I do not want to trespass on your patience, Mr. Deputy Speaker.
1529 The hon. Gentleman asked about changes in the role of ancillary dental workers. He should be aware that the initiative for any changes in function must come from the profession. We are dealing with a skilled profession, the members of which regulate their own practices and discipline. We act in these circumstances almost as a rubber stamp. I hate to describe the House in that way, but we are asked only to dot the i's and cross the t's. Of course, we would seriously consider any proposal on which there was a consensus, but it would be for the GDC to draft amendments to the regulations concerning functions.
I accept that ancillary workers have a role, but here again we are up against the difficulty that dentists are independent contractors and not employees of the NHS, the Government, my Department or anyone else. It is up to them whether they employ dental hygienists and which duties, within the provisions of the Dentists Act, are allotted to them.
I am glad that the hon. Gentleman has welcomed the regulations and I hope that the House will approve them.